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Home My WebLink AboutApplication and WC��"� �iN�#�fit��!�...�°��,�` �)/:"✓/'1 `*�*�'`��* TOWN OF YARMOUTH BOARD OF HEALTH � � � APPLICATION FOR LICENSF�ER:A�IT=:- i4`�� '�.� �.L� 02 �013 * Please complete form and attach all neces�� e t y ece ` Fai lure to do so wi l l resu lt in t he re t�rn q f yQ�r app lica ti • ESTABLISHMENT NAME: i TAX ID: - LOCATION ADDRESS: ` ` � �ITEL.#: - � MAILING ADDRESS: ' E-MAIL ADDRESS:` 'i r OW�TER NAME: ' � CORPORATION NA IF A PLICABLE)• ' C'� ' � w� .J� MANAGER'S NAME: TEL.#: - �a-`�FS`c�� MAILING ADDRESS: 14 POOL CERTIFICATIONS: The pool supervisor must be certi�ed as a Pobl Operator,as required by State law. Please list the designated Pool Operator(s) and attach a copy of the certification to this form. L 2. Pool operators must list a minimum of two employees currently certified in basic water safety, standard First Aid and Community Cardiopulmonary Resuscitation(CPR),having one certified employee on premises at all times. Please list the employees below and attach copies of their certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2. 3. 4. FOOD PROTECTION MANAGERS - CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who is certified as a Food Protect,jsu�� Manager, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.000. Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a �le at your establishment. 1. 2• PERSON IN CHARGE: Each food establishment must have at least one Person In Charge (PIC) on site during hours of operation. 1. 2• ALLERGEN CERTIFICATIONS: All food service establishments are required to have at least one full-time employee who has Allergen certification,as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). Please attach copies of certification to this application. The Health Department will not use past years' records. You must provide new copies and maintain a file at your establishment. 1. 2. . HEIMLICH CERTIFICATIONS: All food service establishments with 25 seats or more must have at least one em�loyee trained in the Heimlich Maneuver on the premises at all times. Please list your employees trained in anti-choking procedures below and attach copies of employee certifications to this form. The Health Department will not use past years' records. You must provide new copies and maintain a file at your place of business. 1. 2• 3. 4. RESTAURANT SEATING: TOTAL# OFFICE USE ONLY LODGING: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# B&B $55 CABIN $55 _MOTEL $55 �INN $55 CAMP $55 _SWIMMING POOL $80ea. LODGE $55 _TRAILERPARK $105 _WHIRLPOOL $80ea. FOOD SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRED FEE PERMIT# 0-100 SEATS $85 _CONTINENTAL $35 NON-PROFIT $30 �>100 SEATS $160 1 COMMON VIC. $60 _WHOLESALE $80 —RESID.KITCHEN $80 RETAIL SERVICE: LICENSE REQUIRED FEE PERMIT# LICENSE REQUIRF,D FEE PERMIT# LICENSE REQUIRED FEE PERMIT# <50 sq.ft. $50 >25,000 sq.ft. $225 _ VENDING-FOOD $25 =<25,000 sq.ft. $80 —FROZEN DESSERT $40 TOBACCO $95 NAME CHANGE: ��s AMOUNT DUE _ $ �.7�,C�C'� *****PLEASE TURN OVER AND COMPLETE OTHER SIDE OF FORM***** _ -�- � ;, `*.,,....� ADMINISTRATION Under Chapter 152, Section 25C, Subsection 6,the Town of Ya.rmouth is now required to hold issuance or r`enewal of any license or permit to operate a business if a person or company does not have a Certificate of Worker's Compensation Insurance. THE ATTACHED STATE WORK�R'S COMPENSATION INSURANCE AFFIDAVIT MUST BE COMPLETED AND SIGNED, OR CERT. OF INSURANCE ATTACHED OR WORKER'S COMP. AFFIDAVIT SIGNED AND ATTACHED Town of Yarmouth taxes and liens must be paid prior to renewal or issuance of your permits. PLEASE CHECK APPROPRIATELY IF PAID: YES NO MOTELS AND OTHER LODGING ESTABLISHMENTS TRANSIENT OCCUPANCY: For purposes of the limitations of Motel or Hotel use, Transient occupancy shall be limited to the temporary and short term occupancy, ordinarily and customarily associated with motel and hotel use. Transient occupants must have and be able to demonstrate that they maintain a principal place of residence elsewhere. Transient occupancy shall generally refer to continuous occupancy of not more than thirty(30)days,and an aggregate of not more than ninety(90)days within any six(6)month period. Use of a guest unit as a residence or dwelling unit shall not be considered transient. Occupancy that is subject to the collection of Room Occupancy Excise, as defined in M.G.L. c. 64G or 830 CMR 64G, as amended, shall generally be considered Transient. POOLS POOL OPENING:All swimming,wading and whirlpools which have been closed for the season must be inspected by the Health Department prior to opening. Contact the Health Department to schedule the inspection three (3) days prior to opening.PLEASE NOTE:People are NOT allowed to sit in the pool area until the pool has been inspected and opened. POOL WATER TESTING: The water must be tested for pseudomonas,total coliform and standard plate count by a State certified lab, and submitted to the Health Department three (3) days prior to opening, and quarterly thereafter. POOL CLOSING: Every outdoor in ground swimming pool must be drained or covered within seven (7) days of closing. _ _ __ _ _ _ _ __ -- _ _ _-- __---- FOOD SERVICE SEASONAL FOOD SERVICE OPENING: All food service establishments must be inspected by the Health Department prior to opening. Please contact the Health Department to schedule the inspection three (3) days prior to opening. CATERING POLICY: Anyone who caters within the Town of Yarmouth must notify the Yarmouth Health Department by filing the required Temporary Food Service Application form 72 hours prior to the catered event. These forms can be obtained at the Health Department, or from the Town's website at www.varmouth.ma.us under Health Department, Downloadable Forms. FROZEN DESSERTS: Frozen desserts must be tested by a State certified lab prior to opening and monthly thereafter, with sample results submitted to the Health Department. Failure to do so will result in the suspension or revocation of your Frozen Dessert Permit until the above terms have been met. OUTSIDE CAFES: Outside cafes (i.e., outdoor seating with waiter/waitress service),must have prior approval from the Board of Health. OUTDOOR COOKING: Outdoor cooking,preparation, or display of any food product by a retail or food service establishment is prohibited. -_ . _ . _. _ _ _ __ NOTICE: Permits run annually from January 1 to December 31. IT IS YOUR RESPONSIBILITY TO RETURN THE COMPLETED RENEWAL APPLICATION(S) AND REQUIRED FEE(S)BY DECEMBER 13, 2013. ALL RENOVATIONS TO ANY FOOD ESTABLISHMENT, MOTEL OR POOL (i.e., PAINTING, NEW EQUIPMENT, ETC.), MUST BE REPORTED TO AND APPROVED BY THE BOARD OF HEALTH PRIOR TO COMMENCEMENT. RENOVATIONS MAY REQ A SITE PLAN. DATE: ,..3 SIGNATURE: � ��,,�. �,�� ..� ._.� PRINT NAME &TITLE: ` �-. Rev. 10/08/13 � � � � �� CERTIFICATE OF LIABILITY INSURANCE �11/22/2013Y� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certifcate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement s. PRODUCER CONTACT NAME KIRKILES&ASSOCIATES a°NN Ex�:781-659-3300 ___ a( C No�81-659 3366 COMMERCIAL INSURANCE BROKERAGE LLC ADDRESS: Y7$RIVER STREET � INSURER(S)AFFORDING COVERAGE NAIC# � - ----_.._--------__. NORWELL,MA 02061-2209 iNsuReRn: MASS RETAIL MERCHANTS � INSURED . � � INSURER B: ANTHONY'S CUMMAQUID INN, INC. wsuReRa _ RT.F)A � INSURER D: � � . _ __—._---- _ . ____ YARMOUTHPORT,MA 02675 iNsuReRe: ___ __ �NSURER F: COVERAGES CERTIFICATE NUMBER: 101440 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. — ----- _ _-- ---- - - - -_ INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR ____TYPE OF INSURANCE INSR WVD POLICY NUMBER _ MMIDDlYYYY MMIDD/YYYY) ._. - - -- GENERAL LIABILITY � � EACH OCCURRENCE �$ - DAMAGE TO RENTED � �� COMMERCIAL GENERAL LIABILITY .PREMISES(Ea occurrence)_�$ _ _,CLAIMS-MADE �OCCUR � MED EXP(Any one person) $ _ ____ PERSONAL&ADV INJURY '�$ -- - - -.__._- ----.._..__ GENERALAGGREGATE $ --- - --- -- -_ . - GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ _ ,� n -_ --- ___ � _ AUTOMOBILE LIA PRO _�$ J � POUCY �JECT LOC � --- -- --- --_.-- -._. _ � � �� -- COMBINED SINGLE LIMIT� - � -�� BILITY� $ ... (Ea accidenQ . -- - ---.._--------------___._ ...._._------- ANY AUTO � BODILY INJURY(Per person) $ ------. .__... .. . . . �AUTOS NED qUTOSULED BODILY INJURY(Per accident) $ � _- ---- NON-OWNED ��PROPERTY DAMAGE HIRED AUTOS AUTOS . (Per accident) �$ .__ . . _- _. . _. — $ � ---�-- ----._...— - -. . -- _ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ �---- -- __ . _. _ _ EXCESS UAB CLAIMS-MADE � AGGREGATE $ --._.__..__ _-. DED� RETENTION$ I$ __ - ---..._-- --_.__. WORKERS COMPENSATION �7 WC STATU �OTH ��--� A ANDEMPLOYERS'LIABILITY Y�N 0140050310081013 1/1/2013 ��2��4 _X_1TORYlIMITSI .I .ER i .__ ANY PROPRIETOR/PARTNER/EXECUTIVE N�A . E.L EACH ACCIDENT .. �$ SOO,OOO OFFICER/MEMBER EXCLUDED? � � - -� -� � - -- � (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE�$ � 'rJOO,�� f yes,describe under - - � � - DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT $ SOO,OOO ._...I---�- --..__-------- ---�---- ------------- - ��-- -- - ---.... DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE OESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HEALTH INSPECTOR ACCORDANCE WITH THE POLICY PROVISIONS. 99 BUCK ISLAND ROAD W.YARMOUTH,MA 02673 AUTHORIZED REPRESENTATIVE FAX:508-760-3472 �r �iGot.c-`�`�a..xF.<�<cJ I f OO 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD % / O��Y``�� : � ;: :o TOWN OF YARMOUTH , � � 0 � '� 114G ROLTE 28 SOUTH�:�RDZOUTH '�IASSACHtiSETTS 026G4-4451 � MATTAGHEES � �/��o011Aft0�6�� Telephone (5081 398-2231, E�:t. 1241 — Fa� �508j 760-3472 �U B O A R D O F H E A L T H December 3, 2013 Anthony's Cummaquid Inn, Inc. \ Attn: Anthony Athanas, Jr. 299 Salem Street Swampscott, MA 01907 Re: 2014 License Application Anthony's Cummaquid Inn, 2 Route 6A, Yarmouthport, MA Dear Mr. Athanas, Thank you for submitting the 2014 application for your establishment's food service and common victualler licenses issued through the Health Department. Please note tha �.' `�*�`�� ;��'r�usi�+er'�� +��3�t��,.. ��i��,e+�e�tio�,' a�d ��imliE+ch l�i�+�ver ;; ��ex�io�s a�e required to be submitted with the application. All food service establishments are required to have at least one full-time employee who is certified as a Food Protection Manager, as defined in the State Sanitary Code for Food Service �. establishments, 105 CMR 590.000. All food service establishments are required to have at least one fizll-time employee who has Allergen certification, as defined in the State Sanitary Code for Food Service Establishments, 105 CMR 590.009(G)(3)(a). All food service establishments with 25 seats or more must have at least one employee trained in the Heimlich Maneuver on the premises at all times. Please note that the Health Department cannot use past year's records,as we are unable to verify if those staff inembers are still under your employment. As soon as our office receives the above noted certification copies,we will be able to complete the processing of the licenses. If you have any questions on the above, please feel free to contact our office at (508)398-2231, extension 1241. Tha.nk you for your anticipated cooperation. Sincerely, . Mary Alice Florio Principal Department Assistant /maf cc: file